I human case week #4 For A 2 year old
female patient reason for encounter Ear pain
and fever.
Patient Information
• Age: 2 years old
• Height: 2'9" (84 cm)
• Weight: 27 lbs (12.3 kg)
• Location: Outpatient clinic with laboratory capabilities
• Reason for Encounter: Ear pain and fever
History and Feedback
, Pivotal Concept Areas Addressed:
1. Ear Pain and Fever in Pediatric Patient – Commonly associated
with otitis media or other pediatric infections.
2. Communication with Pediatric Patients and Caregivers – Essential
to obtain history from caregiver (likely the mother).
3. Fever Management and Pain Assessment in Toddlers – Requires
both subjective caregiver input and objective assessment.
4. Vaccination Status – Can guide differential diagnoses, e.g., Hib or
pneumococcal coverage.
History Taking (Subjective Data):
• Onset of Symptoms: Likely within the last 1–3 days (common in
otitis media).
• Associated Symptoms: Possible irritability, tugging at ears, poor
appetite, disturbed sleep.
• Fever Characteristics: Duration, how high it gets, response to
medications.
• Daycare Exposure: Relevant for infections.
• Feeding Pattern and Activity: Changes can indicate severity.
• Past Medical History: Birth history, prior ear infections,
immunization status.
• Medications Tried: Any OTC analgesics like acetaminophen or
ibuprofen?
Case Problem Statement (Case Finding)
female patient reason for encounter Ear pain
and fever.
Patient Information
• Age: 2 years old
• Height: 2'9" (84 cm)
• Weight: 27 lbs (12.3 kg)
• Location: Outpatient clinic with laboratory capabilities
• Reason for Encounter: Ear pain and fever
History and Feedback
, Pivotal Concept Areas Addressed:
1. Ear Pain and Fever in Pediatric Patient – Commonly associated
with otitis media or other pediatric infections.
2. Communication with Pediatric Patients and Caregivers – Essential
to obtain history from caregiver (likely the mother).
3. Fever Management and Pain Assessment in Toddlers – Requires
both subjective caregiver input and objective assessment.
4. Vaccination Status – Can guide differential diagnoses, e.g., Hib or
pneumococcal coverage.
History Taking (Subjective Data):
• Onset of Symptoms: Likely within the last 1–3 days (common in
otitis media).
• Associated Symptoms: Possible irritability, tugging at ears, poor
appetite, disturbed sleep.
• Fever Characteristics: Duration, how high it gets, response to
medications.
• Daycare Exposure: Relevant for infections.
• Feeding Pattern and Activity: Changes can indicate severity.
• Past Medical History: Birth history, prior ear infections,
immunization status.
• Medications Tried: Any OTC analgesics like acetaminophen or
ibuprofen?
Case Problem Statement (Case Finding)
